858 infection control & hospital epidemiology july 2017, vol. 38, no. 7
Admissions, no.a Patient days, no.
table 1. Inpatient Medicine Firms and Reviewed Antimicrobial Cases Control Firm 1,942
7,993
Length of stay, median d (range) Antimicrobial courses
Cases randomly selected for error adjudication Cases reviewed, no. (%) Age, mean y (SD) Females, no. (%)
ED antimicrobial course starts, no. (%)
Antimicrobial indicationsb Lower respiratory, no. (%) Upper respiratory, no. (%) Urinary tract, no. (%) Skin/Soft tissue, no. (%) Intra-abdominal, no. (%) Febrile neutropenia Clostridium difficile Other
4 (1–59) 877
144 (28.9) 52.8 (15.3) 64 (44)
112 (77.8)
45 (31) 3 (2.1)
26 (18.1) 27 (18.8) 24 (16.7) 4 (2.8) 9 (6.2)
35 (24.3)
Education Firm 1,920
9,587 5 (1–88) 904
178 (35.7) 53.4 (16.1) 91 (51)
148 (83.2)
73 (41) 2 (1.1)
34 (19.1) 34 (19.1) 25 (14.0) 5 (2.8)
11 (6.2) 60 (33.7)
NOTE. SD, standard deviation; ED, emergency department. aAll patients admitted to that firm during the intervention period (February to July, 2005). bEach case can have more than one indication so the sum percentages may exceed 100%.
table 2. Antimicrobial Regimen Error Rates Control
Overall Antimicrobial Errors
Initial regimen with error, no. (%) Any error during therapy
DOT with error / Total DOT (%) Mean DOT with error per courseb Any error
Too narrow-spectrum Safety issue
Antimicrobials not needed Too broad-spectrum or complex n/N (%)
96/144 (66.7) 112/144 (77.8) 292/612 (47.7) Days 2.1 0.5 0.1 0.6 0.8
Education n/N (%)
129/178 (72.5) 152/178 (85.4) 461/862 (53.5) Days 2.6 0.8 0.1 0.8 0.9
P Valuea .26
.08 .03
P Valuec .31 .07 .35 .96 .43
Pharmacist Intervention n/N (%)
129/176 (73.3) 156/176 (88.6) 484/886 (54.6) Days 2.8 0.4 0.1 0.8 1.4
NOTE. DOT, antimicrobial days of therapy. aχ2 analysis of proportions relative to control. bThe mean DOT per antimicrobial course, regimens could have >1 error type. cNegative binomial regression, test of intervention error days vs control, offset for total days of therapy.
clinician education firm exceeded 80% of resident physicians and 50% of attending physicians. Infectious disease pharmacists reviewed 567 of 901 antimicrobial courses (62.9%) given in their firm, generating 202 (35.6%) recommendations for improvement, of which 129 (63.9% of the recommendations conveyed; 14.9% of total antimicrobial courses) were accepted. Recommendations that would reduce overall antimicrobial use (ie, to discontinue therapy or simplify redundant regimens)were made 94 times and were accepted 43 times. Moreover, 1 or more antimicrobial use errors were identified
Attendance at each of the 12 teaching sessions presented to the
in 420 of the 498 case vignettes reviewed (84.3%), including errors in the initial antimicrobial regimen in 354 (71.1%), and errors were identified during 1,237 (52.4%) of the 2,389 days of therapy reviewed (Table 2). The proportions of antimicrobial courses, course initiations, and treatment days with 1 or more
errors at any time and the mean number of days per antimicrobial course during which specificerror types were identified were higher in the education firm and in the pharma- cist intervention firm than in the control firm. However, these differences held variable statistical significance (Table 2). Weekly antimicrobial use rates for each of the 3 firms during the
24-week intervention period were highly variable and frequently overlapped, with no suggestion of reduced antimicrobial use in either intervention firm compared with the control firm (data not shown).
discussion
When concurrently deployed over 24 weeks in operationally equivalent inpatient medicine firms, neither clinician education nor prospective audit and feedback was associated with
Total
P Valuea .20
.01 .01
P Valuec .15 .37 .46 .64 .22
n/N (%)
354/498 (71.1) 420/498 (84.3)
1,237/2,360 (52.4) Days 2.5 0.6 0.1 0.8 1.0
Pharmacists’ Firm 1,942
9,040 5 (1–56) 901
176 (35.3) 54.2 (15.7) 93 (53)
135 (76.7)
77 (43.8) 2 (1.1)
30 (17.1) 30 (17.1) 25 (14.2) 6 (3.4) 7 (3.9)
61 (34.7)
Total 5,804
26,620 …
2,682
498 (100) 53.5 (15.7) 248 (49.8) 395 (79.3)
195 (39.1) 7 (1.4)
90 (18.1) 91 (18.3) 74 (14.9) 15 (3.0) 27 (5.42) 156 (31.3)
P Value …
…
<.001 …
.07 .70 .30 .30
.06 .70 .90 .80 .80 .90 .50 .09
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